The watchdog agency for the federal Department of Veterans Affairs says staff at the Tomah VA Medical Center failed to report a dentist who used improperly sterilized equipment for more than nine months and found surprise inspections could have alerted hospital leaders sooner.
The findings are contained in a report released Thursday by Office of Inspector General on its investigation into the lapse in hygiene, which could have exposed hundreds of veterans to bloodborne infections, including HIV and hepatitis.
In November, the Tomah VA asked nearly 600 patients to get screenings after learning of the violations. Spokesman Matthew Gowan said as of Thursday more than 90 percent of those patients had been tested with no confirmed infections.
The VA has flagged electronic records of the remaining patients to alert their physicians to follow up on their next visit, according to the IG report, which determined facility leaders took appropriate actions once alerted to the problem.
The dentist, identified as Thomas Schiller in an internal VA report submitted to Congress, was suspended and resigned in December.
The investigation — conducted at the request of Wisconsin’s two senators and Reps. Ron Kind of La Crosse and Tim Walz of Minnesota — recommends unannounced inspections of the dental clinic, training for staff on when and how to report issues relating to patient safety and consultation with VA leadership on any action to take against staff who failed to report the use of unsterilized instruments.
Tomah VA Director Victoria Brahm said the clinic has followed through on all the IG’s recommendations.
“I think the findings were fair,” Brahm said. “We’ve done everything that we’ve been asked to do.”
Both the internal and IG reports makes clear that Schiller knowingly violated VA policy but the internal report also points to problems with a hostile work environment, which was also cited as a factor in the over-prescription of painkillers revealed in 2015.
According to the internal VA report, Schiller used his own bits — known as burs — and other personal supplies over the objections of his assistant. Schiller said he was aware that he was only allowed to use VA equipment but admitted using personal equipment and cleaning it in accordance with private sector protocols.
The assistant said she reported the policy violation in December 2015 to the lead hygienist, who reportedly told her “not to worry about it” and that “he would get caught sooner or later.”
Schiller wasn’t caught until Oct. 19 — more than a year after he was hired — when a substitute hygienist witnessed him use a personal bur and reported it to another dentist.
According to the internal review, Schiller used unsterilized burs on approximately 112 of the 592 patients he treated during his year with the VA and used other personal supplies on about 243 of those patients.
According to the OIG report, the lead hygienist said she instructed Schiller’s hygienist to report the violations to Dr. Frank Marcantonio, the chief of dental services and Schiller’s supervisor. The lead hygienist, who has since retired, told investigators she didn’t report it because she had not personally witnessed a violation.
Staff members also said Schiller had poor hand-washing habits, didn’t always follow cleaning protocols and slept during clinical hours, although the OIG said they did not report the behavior.
The hygienist said she was afraid to turn Schiller in, according to the report, which also cited a hostile work environment “as a potential cause of his diversion from known protocol.”
Brahm said an unannounced visit by the Joint Commission, an independent organization which accredits all U.S. hospitals, found no evidence to support hostile workplace allegations.
“One thing we do not ever tolerate is bullying,” Brahm said.
Marcantonio has since left the VA, and neither he nor Schiller cooperated with the OIG investigation, although Schiller submitted a letter. He also made allegations about the cleaning process used in the dental lab, which were referred to the OIG’s hotline.
According to the VA’s internal report, Schiller’s clinical privileges were revoked and he was reported to regulators in Texas, where he was licensed in 1996, and to the National Practitioner Data Bank, a federal clearinghouse designed to prevent health professionals from moving to another state without disclosing malpractice payments or other red flags.
The Texas State Licensing Board lists no disciplinary actions against Schiller.
The Tomah medical center was at the center of an 18-month Congressional investigation that culminated with a top VA official acknowledging a “clear and inexcusable lack of leadership” was to blame for the deaths of at least two veterans.
That investigation began after 2015 media reports detailed high levels of opioid prescription and a pervasive culture of intimidation and retaliation against employees who spoke out. Two top officials from Tomah — Director Mario DeSanctis and Chief of Staff Dr. David Houlihan — were removed in the wake of that report, and Houlihan later surrendered his medical license.
U.S. Sen. Ron Johnson, a Republican who chairs the Senate committee with VA oversight, issued a statement Thursday saying he is glad the dentist no longer works for the VA.
“His actions were more than disturbing and provoked my request for the VA inspector general to conduct an investigation,” Johnson said. “I will continue my oversight to ensure that the finest among us receive the quality care that they deserve.”
Sen. Tammy Baldwin, who has come under fire from Republicans for her response to reports of opioid abuse, issued a statement Thursday saying she’s “extremely troubled” that Schiller was able to avoid questioning by resigning. Baldwin, a Democrat, said she is drafting legislation to give the OIG the power to subpoena testimony from former VA employees.
“A resignation or a retirement shouldn’t prevent a bad actor from being held accountable,” Baldwin said.